Clinic patient jr is a 46-year-old left handed man, chief complaint of headache and "episodes"

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Headache Cases

Case 1:

Clinic patient JR is a 46-year-old left handed man, chief complaint of headache and “episodes”

• 5-month history of headaches. He complains of metallic taste in his mouth followed by visual disturbance which he describes as ‘cloudiness’ and tingling of his left hand and left side of his tongue. This lasts for 5-15 minutes and is followed by headache. The headache is bitemporal, throbbing, and lasts for a few minutes to an hour in duration. It occurs 2-3 times a week.

• Not associated with photophobia, phonophobia, and nausea or vomiting

• Not worsened with movement– no significant disability

• Prior to 5 months ago headaches were a few/year and triggered by excessive coffee or alcohol (beer)

Question 1: What are JR’s Red Flags? (hint: 3)

Question 2: What testing would prove most helpful in this patient?
􀂉 Electroencephalogram (EEG)
􀂉 Computed tomography (CT) head scan
􀂉 Laboratory testing
􀂉 Magnetic resonance (MR) head scan

Case 1 continued:

He is diagnosed with a R sphenoid ridge meningioma causing focal seizures and secondary headaches. He is referred to neurosurgery.

JR returns for follow up 6 months after surgical resection of tumor. He has decreased sensation to pinprick on right cheek in V2 distribution, which has been persistent since surgery. He now has a different headache complaint. These headaches are severe headaches (9/10 pain intensity), throbbing and worsened with movement, and associated with sensitivity to light and sound. They occur 1 every 1-2 months, last 1-2 days and may be preceded by ‘seeing spots’ for 10-15 monutes before the headache begins.

Question 3: What might be the correct diagnosis for JR at this point?
􀂉 Seizure
􀂉 Migraine with aura
􀂉 Migraine without aura

􀂉 Recurrent brain tumor

Question 4: What would be appropriate first line abortive treatment





Case 2:

SE is a 45 yo female with complaint of mild headaches almost every day, and debilitating headache 2-6/mo. She describes the severe headaches as an achy pressure sensation including the occiput, neck and forehead. It is moderate to severe in intensity, throbbing, causing vomiting. They started when she was a teen, but have worsened over the years. She has seen 2 neurologists in the past, and had a normal MRI. She is currently taking topirimate 100mg daily,

Ibuprofen 200mg 2 tabs every morning and afternoon for mild headache days, and Triptans 2-3 times per week for severe headache which are usually effective.
She describes triggers as chinese food, ice cream, chocolate, alcohol and menses. She also mentions increased work stress seems to make headaches worse but denies anxiety or depression.
Question 5: Which of the following are the most likely diagnoses for this patient? (hint: more than 1)
􀂉 Migraine
􀂉 Tension-type headache
􀂉 Medication-overuse headache
􀂉 Headache due to substance withdrawal

Question 6: Which of the following tests should you obtain?
􀂉 Beck Depression Inventory (BDI)
􀂉 TSH for hypothyroidism
􀂉 MRI or CT
􀂉 CBC, electrolytes, EKG

Clinical Course


Withdrawal: Patient’s ibuprofen was stopped. Diazepam and procholrperazine was given for 7 days.

– Warned the patient that headaches may worsen during withdrawal phase

Prevention: Topiramate was continued

Acute: A triptan was provided as an acute agent to be used a maximum

of 2 out of 7 days

– Address the likelihood of break-through migraine even while on


Rescue: Prochlorperazine 25 mg by suppository if she exceeded her

quota of triptan

– Discuss side effect of sedation, which may prove helpful

Educational and Behavioral

– Increase awareness of anxiety as a trigger to headache

– Learn relaxation and cognitive techniques to reduce


Education & lifestyle changes

– Limit use of caffeine to 1 cup/serving per day

– Track hormone fluctuations menses/ovulation

– Maintain routine sleep and eating schedules

– Restrict use of all analgesics

– Use diary to identify exacerbating factors/triggers

– Exercise three times weekly for 45 minutes each time

Question 7: Which of the following medications are

implicated in causing medication overuse headache? (note- choose more than 1)

􀀹 Analgesics
􀀹 Caffeine
􀂉 Antiepileptics
􀀹 Triptans
􀀹 Opiates/narcotics/barbiturates

Question 8: Which of the following are true regarding the epidemiology of medication overuse headache?
􀂉 Prevalence of medication overuse headache is between 1 and 5%
􀂉 The most common cause of migraine-like and tension-type headache symptoms that occur on

15 days per month or more is medication overuse

􀂉 Medication overuse headache is defined as the total monthly use of all types of pain or

headache medications

􀂉 Medication overuse headache does not occur in children or adolescents
Case 3:

DM is a 35 yo female with complaints of pain in right face and temple which occur daily for 30-40 minutes. Typically the pain awakens her from sleep, but it may occur again in the afternoon. It is severe in intensity and she has lacrimation and photophobia on side of pain. It has been going on for 2 years in duration.

She denies aggravating factors and says that high dose of anti-inflammatory (12-16 tablets of ibuprofen daily) or Fioricet give her partial relief.

She has no other medical conditions, regular menses, negative history of surgeries or trauma and laboratory evaluations all normal.

Review of systems: negative

Physical exam normal with exception of minor conjunctival inflammation

Question 9: Which of the 2 following are possible diagnoses for this patient?

􀂉 Migraine

􀂉 Cluster headache
Tension headache
􀂉 Chronic paroxysmal hemicranias

Question 10: Which treatment is effective in chronic paroxysmal hemicrania?
􀂉 indomethacin
􀂉 ibuprofen
􀂉 topiramate
􀂉 sumatriptan

Question 11: Which treatments are effective for aborting a cluster headache?
􀂉 oxygen inhalation (8-10 L/min 100% oxygen)
􀂉 indomethacin
􀂉 valproic acid
oral steroids

sumatriptan SQ

Question 12: Which treatments are effective for preventing cluster headache?


valproic acid


Lithium carbonate

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